Chest：肥胖症患者重症监护病房拔管失败的发生率、危险因素和长期结局：一项多中心前瞻性观察性研究的回顾性分析

Abstract

Background: No large observational study has compared the incidence and risk factors for extubation failure within 48 hours and during intensive care unit (ICU) stay in the same cohort of unselected critically ill patients with and without obesity.

背景：目前还没有大型观察性研究比较在同一个未选择的危重病人队列中，有无肥胖症的病人在48小时内拔管失败的发生率和风险因素，以及在重症监护病房（ICU）住院期间的情况。

Research question: Which are the incidence and risk factors of extubation failure in patients with and without obesity?

研究问题：有无肥胖症的病人拔管失败的发生率和风险因素是什么？

Study design and methods: In this prospective multicenter observational FREE-REA study in 26 intensive care units, the primary objective was to compare the incidence of extubation failure within 48 hours in patients with and without obesity. Secondary objectives were to describe and to identify the independent specific risk factors for extubation failure using first a logistic regression model and second a decision tree analysis.

研究设计与方法：在这项前瞻性多中心观察性FREE-REA研究中，26个重症监护病房的主要目标是比较有无肥胖症的病人在48小时内拔管失败的发生率。次要目标是描述并识别拔管失败的独立特定风险因素，首先使用逻辑回归模型，其次使用决策树分析。

Results: Of 1,370 extubation procedures analyzed, 288 (21%) were performed in patients with obesity and 1082 (79%) in patients without obesity. The incidence of extubation failure within 48 hours among patients with or without presence of obesity was 23/288 (8.0%) versus 118/1082 (11%) respectively; unadjusted odds ratio (OR) 0.71 95% confidence interval (CI, 0.45-1.13), P=0.15); alongside patients with obesity receiving significantly more noninvasive ventilation (87/288, 30% versus 233/1082, 22%, P=0.002) and physiotherapy (165/288, 57% versus 527/1082, 49%, P=0.02) than patients without obesity. Risk factors for extubation failure also differed according to obesity status: female gender [adjusted (a)OR 4.88 95%CI(1.61-13.9), P=0.002] and agitation before extubation [aOR 6.39 95%CI (1.91-19.8), P=0.001] in patients with obesity; absence of strong cough before extubation [aOR 2.38 95%CI (1.53-3.84), P=0.0002] and duration of invasive mechanical ventilation before extubation [aOR 1.03 per day 95%CI (1.01-1.06), P=0.01] in patients without obesity. The decision tree analysis found similar risk factors.

结果：在分析的1370次拔管程序中，288次（21%）是在有肥胖症的病人中进行的，1082次（79%）是在没有肥胖症的病人中进行的。有无肥胖症的病人在48小时内拔管失败的发生率分别为23/288（8.0%）和118/1082（11%）；未调整的优势比（OR）为0.71，95%置信区间（CI）为0.45-1.13，P=0.15）；同时，有肥胖症的病人接受无创通气（87/288，30%对比233/1082，22%，P=0.002）和物理治疗（165/288，57%对比527/1082，49%，P=0.02）的比例显著高于无肥胖症的病人。根据肥胖状况，拔管失败的风险因素也有所不同：女性[调整后（a）OR 4.88 95%CI（1.61-13.9），P=0.002]和拔管前躁动[aOR 6.39 95%CI（1.91-19.8），P=0.001]在有肥胖症的病人中；拔管前无强咳嗽[aOR 2.38 95%CI（1.53-3.84），P=0.0002]和拔管前侵入性机械通气的时间[aOR 每天1.03 95%CI（1.01-1.06），P=0.01]在无肥胖症的病人中。决策树分析发现了类似的风险因素。

Interpretation: Our findings indicate that anticipation and application of preventive measures for patients with obesity before and after extubation led to similar rate of extubation failure among patients with and without obesity.

解释：我们的发现表明，对有肥胖症的病人在拔管前后采取预防措施的预期和应用，使得有无肥胖症的病人拔管失败率相似。